Service/Facility Dog Inquiry

Service/Facility Dog Inquiry

PGI Service Dog Inquiry

Filling out an inquiry for a service dog program is the first step in our application process. At this stage, we ask for basic information about your needs and eligibility, which allows us to better understand how a service dog could potentially support you. Please note that completing the inquiry form does not guarantee approval or enrollment in the program. It simply helps us assess your situation and determine if a service dog is the right solution for your needs. After reviewing your inquiry, we may reach out for further clarification or to discuss next steps, which may include submitting additional documentation or undergoing a more detailed assessment before any decisions can be made.

Todays Date *

Name of Applicant for the Dog *

First

Last

Name of Person completing this Inquiry *

First

Last

Date of Birth of the applicant for the dog *

I am applying for the following type of dog: *

• Service Dog: a dog that works for individuals with disabilities other than blindness or deafness. Service dogs are trained to perform a wide variety of tasks including but not limited to; pulling a wheelchair, bracing, retrieving, alerting to a medical crisis, and providing assistance in a medical crisis.
• Skilled Facilited Service Dog: The indivdual with a disability is unable to handle the dog alone or complete all of the care need for the dog (feeding, cleaning up after the dog, ect), do they will need a facilitator to be trained to handle the dog to assist them,
• Hearing Service Dog: A dog that alerts individuals who are deaf or hard of hearing to specific sounds. The presence of a dog for protection, personal defense, or comfort does not qualify that dog as a hearing dog.
• A Partial Sight Service Dog: is a dog that has been specially trained to assist individuals with partial vision loss or low vision. These dogs help with tasks that make navigating the environment safer and easier for people who have limited vision. While they don’t provide the same level of guidance as a full guide dog (which is typically used by individuals who are completely blind), partial sight service dogs still help with things like avoiding obstacles, guiding around hazards, and improving mobility.
• Other- Please explain below

Other:

Email *

Phone *

Your Home Address *

Address Line 1

Address Line 2

City

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Zip Code

Have you lived in the same home/ appt for the last 6 months? *

• Yes- I can provide proof of 6 months residency
• No- I have moved in the last 6 months

How many places have you lived in the last 12 months? *

Is this home categorized as: *

• Skilled nursing facility (SNF), Independent living centers (ILCs), Intermediate Care Facilities (ICFs), Group Home,Nursing Home, Residential care facility, Assisted living facility
• Supportive living environment, Long-term care residence
• Rehabilitation centers
• Shared housing / roommate arrangements
• Living with parents, siblings, or relatives
• NA- I live independently in my Primary residence

What is your living situation; I live in my own house, I live in an assisted living situation, I live with a family member or friend, other- please explain

ALL APPLICANTS: Describe your Home and Liftestyle

Where do you live *

• Single Family Home
• Townhome
• Apartment
• Other

Do you rent or own? *Home OwnerRent

How did you hear about PGI? *

Who lives in the home (please list all adults, children and family)? *

What animals live in the home? (include how many dogs and how many other animals) *

Are all the animals in the home up to date on vaccinations? *NoYes

Are all the animals in the home spayed/neutered? *NoYes

What is your current daily Level of activity Semi Active Active *

• Active (I leave my home daily)
• Semi Active (I leave my home at least 3 times a week)
• Home Bound (I leave my home 1 time a week or less)
• I spend the majority of my day in bed

Are there any areas in your home, job or the facility that would pose a safety concern for a dog (e.g., stairs, sharp objects)? *

Have you ever been convicted of a crime? AND/OR animal neglect or abuse? *

• Yes
• No

If yes please describe

Please include photos of the applicant’s home (inside, outside) and yard. *

Drag & Drop Files, Choose Files to Upload You can upload up to 4 files.

SERVICE DOG QUESTIONS

What is your goal of adding a working dog to your life? *

For a Service dog: please list your medical diagnosis and what TASKS a service dog can do to assist you. *

Task: this is a trained behavior that the dog does on cue (or command) to mitigate its partner’s disability. The cue can be verbal, a hand signal, something in the environment and/or some behavior exhibited by the partner or another person. Examples of a verbal cue could be “take it” and a hand signal could be pointing at an object to indicate to the dog to retrieve it. A cue in the environment might be a strap on a door, a car in the road or an alarm clock ringing. The behavior of a person could be falling to the ground, hand shaking, or emitting odor of low blood sugar.

What do you understand about the role and responsibilities of having a working dog? *

Do you have any medical conditions that might impact your ability to care for a service dog? (e.g., physical or cognitive limitations- can you walk a dog, feed a dog, etc)? *

Do you live in a place where a dog is allowed (e.g., landlord approval, pet policies)? How would you handle your dog when you're at work, in public spaces, or traveling?

What are your expectations for the working dog? Are you prepared for the training and commitment that comes with having a wokring dog? How do you feel about having a dog in public spaces, and how would you handle potential distractions or situations that could arise? *

All Applications- Questions related to our program

Do you currently reside in illinois? *NoYes

Are you able to attend weekly training classes in Peoria IL *

• Yes
• No

Can you afford $600-800 a year for vet care and grooming for a dog? *

• Yes
• No

Are you willing to commit to annual re-certification tests for a working dog and continued training for the life of the dog? *

• Yes
• No

Acknowledgement of the process *

• I understand this is only a basic inquiry form and does not complete my application or approve me for a service dog. Future steps are needed before my application is complete.

Check to acknowledge agreements before submitting inquiry *

• By signing this I understand Paws Giving Independence reserves the right to deny any applicant for any reason. I understand Paws Giving Independence does not have to give me a reason for a denial of an animal. In my participation with Paws Giving Independence and Helping Paws I do hereby agree to hold free from any and all liability the Paws Giving Independence/Helping Paws and its members, board members, staff, volunteers and officers. My family, members of my household and myself waive the rights and claims for damages and injuries, which may come from connection and participation with PGI. I declare myself to be physically sound to participate with the PGI. I understand PGI can remove a dog from my home at any time due to failure to fulfill these terms, conditions, policies, and procedures of Paws Giving Independence. I understand any dog that is placed with me through Paws Giving Independence will legally belong to Paws Giving Independence until placement paperwork is signed. By providing contact information I am giving PGI permission to contact my vet and references. I understand, service dogs are highly trained in many commands, but they are not machines that will respond automatically to commands. I understand a PGI dog cannot take responsibility for the safety of the recipient.

Permission to review information *

• I understand PGI will review my information and decided if I am a fit for moving forward with their program. If they would like more information they will email me a complete application to fill out. This Inquiry does not guarantee me acceptance for a service dog. Our recipients are chosen from those who can best benefit from the skills of our dogs.

Information Accuracy *

• The information contained in this online inquiry is correct to the best of my knowledge.

PGI prohibits discrimination based on race, sex (including pregnancy, childbirth or related medical conditions), religious creed, color, national origin or ancestry, physical or mental disability, medical condition, marital status, age, sexual orientation, citizenship status, military service or veteran status, gender identity and gender expression or any other basis protected by federal, state or local law or ordinance or regulation.

Signature *

Clear Signature

Submit

**WE DO NOT TRAIN DOGS FOR: PTSD-only diagnosis, Emotional support or Personal dogs for service.

 PGI can only accept a limited number of applications annually due to our volunteers and financial resources. Not everyone who applies for a dog will receive a dog. Our board must approve recipients before being taken into the program. If accepted, weekly training in Peoria is required.

Our recipients need to learn, gain, and maintain handler qualities. These qualities include quick decision-making, sound judgment in handling decisions, consistency, and appropriate memory.

Minimum requirements to be considered for a PGI dog:

• The individual must have a documented disability.
• PGI must be able to train a dog to help with their specific needs.
• All dogs must be kept in the family’s house.
• All animals in the home must live inside and be kept up-to-date on shots by a vet (the vet will be contacted).
• The potential recipient/family must complete 25 hours of training in Peoria, IL.
• The potential recipient/family must complete three home passes where the dog is exposed to other family animals and family members.
• Recipients must be able to attend weekly classes for the life of the dog.